ICU Stay Common in U.S. Hospital Deaths

Action Points

Explain to interested patients that inhospital mortality and patterns of use of intensive care are widely different in the U.S. and England.

Caution that the study did not suggest that one system is safer than the other, but rather may simply reflect different societal expectations.

American patients who die in the hospital are nearly five times more likely than those in England to spend some of their last days in the intensive care unit, according to a cross-national comparison.

Whereas more deaths occurred in the hospital in England (50.3% versus 36.6%), the proportion that involved intensive care was much higher in the U.S. (47.1% versus 10.1%), found Hannah Wunsch, MD, MSc, of Columbia University in New York City, and colleagues.

But whether this reflects overuse on one side of the pond or underuse on the other remains unclear, they cautioned in the Nov. 1 issue of the American Journal of Respiratory and Critical Care Medicine.

Surveys suggest that the majority of patients in both countries prefer not to die in the hospital, and intensive care is not only costly but can potentially worsen the trauma of a hospital death for patients and their families.

"Whether less intensive care for very elderly patients who are dying is a form of rationing, or is actually better recognition of what constitutes appropriate care at the end of life warrants further research," Wunsch said in a written statement.

This is particularly true given the national debate in the U.S. about healthcare reform and the rational allocation of healthcare resources in both countries, commented John Heffner, MD, of Providence Portland Medical Center in Portland, Ore., and past president of the American Thoracic Society.

Although noting limitations of the administrative data used for the study, including whether deaths occurred in the ICU or after an ICU stay earlier in the terminal hospitalization, Heffner speculated:

"More patients die in the hospital in England possibly because the U.S. has developed a more comprehensive system of intermediate care facilities and nursing homes, which receive and transfer dying patients from acute care hospitals."

However, the study can offer no answer to the "why" questions about differences between the two nations, according to an accompanying editorial by Theodore Iwashyna, MD, PhD, of the University of Michigan in Ann Arbor, and Julia Lynch, PhD, of the University of Pennsylvania in Philadelphia.

Nevertheless, the editorialists made a few speculations of their own:

"It may be that their finding of stark differences in use of intensive care reflects differences between American and English norms surrounding patient decision-making, autonomy, and entitlement. Or it may be that, unlike in the U.S., centralized budgeting and allocation of high-dependency units in the U.K. precludes filling beds simply because they are there or turning to ICUs to monitor even low-risk conditions."

Because both systems have roughly similar life expectancies and living conditions, the researchers retrospectively turned to national hospital care databases in England and those from seven U.S. states to compare hospitalization characteristics at the end of life.

During 2001, the nations had an identical population mortality rate of 0.9 per 1,000 population and similar age-adjusted acute hospitalization rates of 110.5 per 1,000 in England and 105.3 per 1,000 in the U.S.

But English patients had much lower overall intensive care service use (only 2.2% of all hospital discharges versus 19.3%).

Over this one-year period, crude hospital mortality was slightly higher in England (4.3% versus 3.0%). The hospital mortality rate for the few who had an ICU stay was much higher (19.6% versus 7.4%), although it was based on small numbers.

Elderly English patients were more likely to spend their last days in a hospital compared with elderly in the U.S. (47.4% versus 31.2%), but even in this 85 and older population comparatively few Brits visited the ICU (1.3% versus 11.0% among U.S. patients).

These differences in care patterns may not be surprising "given that the U.K. has one-sixth the number of intensive care beds per capita," the researchers noted.

They cautioned that the study was limited by lack of data on intensity or quality of care, severity of illness, and expected mortality.

One of the researchers reported being an employee of ZD Associates, a health economics consulting firm.

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